Perioperative medicine : managing surgical patients with medical problems

462 Pages·2009·2.501 MB·English

by  Chikwe, Joanna, Walther, Axel, Jones, Philip

List of emergency topics for quick reference
• ACUTE ABDOMEN b p250
• ANURIA b p214
• ANAPHYLAXIS b p117
• ASTHMA ATTACK b p188
• ACUTE MI b p122
• AIRWAY OBSTRUCTION b p206
• BLEEDING b p98
• BREATHLESSNESS b p180
• CARDIAC ARREST b inside cover
• CHEST PAIN b p120
• COMA b p292
• CONFUSION b p294
• DIABETIC KETOACIDOSIS (DKA) b p278
• FALLS b p321
• HAEMORRHAGE b p98
• HYPERKALAEMIA b p410
• HYPOGLYCAEMIA b p279
• HYPONATRAEMIA b p228
• HYPOTENSION b p116
• GI BLEED b p260
• LOSS OF CONSCIOUSNESS b p302
• PAIN b p78
• PULMONARY EMBOLISM (PE) b p194
• RESPIRATORY FAILURE b p293
• SEIZURES b p306
• SEPSIS b p86
• SHOCK b p116
• STROKE b p298
• TENSION PNEUMOTHORAX b p203
• TRAUMA b p320
ATLS Protocol for major trauma
Primary survey:
Airway maintenance with cervical spine protection
• Protect spinal cord
• Assess airway for patency. If patient can speak airway is ok for now.
• Consider foreign body, facial, tracheal/laryngeal fractures.
• Perform jaw thrust, consider naso-/oropharyngeal airway.
• If patient unable to maintain airway integrity secure a defi nitive airway.
Breathing and ventilation
• Administer high-fl ow O using a non-rebreathing reservoir.
2
• Inspect for chest wall expansion, symmetry, respiratory rate, wounds.
Palpate, percuss, auscultate. Tracheal deviation, s/c emphysema.
• Identify and treat life-threatening conditions: tension pneumothorax,
open pneumothorax, fl ail chest, massive haemothorax.
Circulation with haemorrhage control
• Look for signs of shock (b p.116), cardiac tamponade (b p.128).
• ↓BP usually due to blood loss; bleeding into chest, abdomen, retroperi-
toneum, any fracture.
• Control external bleeding with pressure.
• Wide bore IV access, send blood for XM, FBC, clotting, U&E.
• Commence bolus of warmed Ringer’s lactate solution; unmatched, type
specifi c blood only for immediate life threatening blood loss.
• Consider surgical control of bleeding (laparotomy, thoracotomy).
Disability
• Perform a rapid CNS evaluation. AVPU (Alert, responds to Voice,
responds only to Pain, Unresponsive to all), Glasgow Coma Scale.
• After excluding hypoxia and hypovolaemia, consider changes in level of
consciousness to be due to head injury.
Exposure/Environment control
• Undress patient for thorough examination: prevent hypothermia by
covering with warming device and use warm intravenous fl uids.
Adjuncts to Primary Survey
• Monitoring—noninvasive BP, ECG, pulse oximetry.
• Urinary catheter (after ruling out urethral injury).
• Diagnostic studies—x-rays (lateral cervical spine, AP chest, and AP
pelvis), US scan, CT scan, diagnostic peritoneal lavage.
Secondary survey:
Begin only after primary survey is complete and resuscitation is con-
tinuing successfully. Take history—AMPLE (Allergy, Medication, Past
medical history, Last meal, Events). Perform a head to toe physical
examination. Continue reassessment of all vital signs. Perform specialized
diagnostic tests.
Conversions
1 kPa = 7.3 mmHg = 10 cmH0
2
Reference ranges
Laboratory blood tests
Haematology
Haemoglobin Male 14-18g/dl, Female 12-16g/dl
Haematocrit Male 40-50%. Female 37-47%
MCV Male 80-94fl , Female 81-99fl
White cell count 4-11 x103 cells/µl
Neutrophils 50-70% (2-7.5x103cells/µl)
Eosinophils 1-3% (100-300/µl)
Basophils 0.4-1% (40-100/µl)
Platelets 150-450x103/µl
Coagulation
Prothrombin time (PT) 27-38s
Activated Partial Thromboplastin Time (APTT) 11-13.5s
International normalized ratio (INR) 1.0
Biochemistry (serum) Liver function tests
Sodium 136-145mmol/l ALP 30-135U/l
Potassium 3.5-5.1mmol/l ALT 7-40U/l
Creatinine 70-120µmol/l
Urea <7.5mmol/L Bilirubin 2-17µmol/L
Chloride 95-106mmol/l gGT
Bicarbonate 22-39mmol/l Albumin 30-44g/L
Calcium 2.2-2.6mmol/l Total protein 63-83g/L
Creatinine clearance 90-120mL/min
Arterial blood gases
PaO >10.5kPa 75mmHg
2
Pa CO 4.7-6.0kPa 35-54mmHg
2
pH 7.35 – 7.45
H+ 35 – 45 mmol/l
Base Excess -2 - +2 mmol/l
HCO4.7-5.7kPa 24-30mmol/l
3
SaO >95%
2
30-40%
Pulmonary function tests (marked variation with age, height, and sex)
FVC = Forced vital capacity 3.5 – 5 L
FEV = Forced expiratory volume in 1 second >2.0L
1
FEV / FVC 70-80%
1
PEFR = Peak expiratory fl ow rate 450-600l/min
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Perioperative
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SECOND EDITION
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Perioperative
Medicine
SECOND EDITION
Managing surgical patients with
medical problems
Joanna Chikwe
Consultant Cardiothoracic Surgeon
Mount Sinai Medical Center
New York, USA
Axel Walther
Specialist Registrar in Medical Oncology
and Clinical Research Fellow
Cancer Research UK
Philip Jones
Consultant Intensivist and Cardiothoracic Anaesthetist
St Bartholomew’s Hospital
London, UK
1
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v
Preface
73-year-old Mrs Khan starts complaining of chest pain and looking a bit
grey three days after her total hip replacement. Although many medical
handbooks will help you once you’ve decided she’s having an acute MI,
we would recommend this one. Because this one is written for surgical
patients with medical problems and Mrs Khan may be having a massive PE.
Or be bleeding into her thigh. Or gut. Or she may just be in septic shock.
Or fast AF. Or any combination of these. This book will help you diagnose
and treat these conditions in surgical patients, help you avoid the compli-
cations in the fi rst place, and, if Mrs Khan does need an emergency lapa-
rotomy, it will give you practical advice so you know how much blood to
cross-match, whether to talk to ICU, what to tell her relatives, how to look
after her when she’s back on the ward, and when she might go home.
This is a concise, practical text that gives junior doctors the guidance that
they need to cope with medical problems in surgical patients early in pre-
assessment clinic, the night before surgery, and out-of-hours on the wards
postoperatively. It brings together a didactic, practical approach to prob-
lems with up-to-date guidelines based on current recommendations.
It is aimed at a wide readership—clinicians running pre-assessment clinics
or responsible for assessing emergency and elective surgical admissions,
members of the hospital-at-night team, and students interested in learning
more about the practical management of patients.
JC
AW
PJ
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